Provider Demographics
NPI:1114645843
Name:NORDSTROM, TARA
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:
Last Name:NORDSTROM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5394 COUNTRY CLUB DR
Mailing Address - Street 2:SUITE 103/104
Mailing Address - City:LARKSPUR
Mailing Address - State:CO
Mailing Address - Zip Code:80118-8458
Mailing Address - Country:US
Mailing Address - Phone:303-909-9383
Mailing Address - Fax:
Practice Address - Street 1:9896 ROSEMONT AVE STE 103104
Practice Address - Street 2:
Practice Address - City:LONE TREE
Practice Address - State:CO
Practice Address - Zip Code:80124-4104
Practice Address - Country:US
Practice Address - Phone:303-909-9383
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-18
Last Update Date:2022-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0018345101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional